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Hepatitis

Risk factors	Possible Risk factors
* Epstein-Barr virus Family history HIV infection	Genetics Infectious mononucleosis Autoimmune diseases Immunodeficiency Tobacco Socio-economic status and family features

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Is cardiac catheterization an emergency?

Yes

No

Refer to management of acute coronary syndromes

Confirm patient has ANY of the following indications for cardiac catheterization ❑ Canadian cardiovascular society (CCS) class III (i.e. symptoms with everyday living activities) or class IV angina (i.e. inability to perform any activity without angina or angina at rest) despite medical therapy, OR ❑ Angina plus systolic dysfunction, OR ❑ High-risk stress test finding, defined as ANY of following , OR ❑ Resting LVEF < 35% ❑ High-risk treadmill score (≤ 11) ❑ Severe exercise LVEF < 35% ❑ Stress-induced large perfusion defect ❑ Stress-induced multiple perfusion defects ❑ Large, fixed perfusion defect with LV dilation OR increased lung uptake ❑ LV dilation or increased lung uptake ❑ Stress-induced moderate perfusion defect with LV dilation or increased lung uptake ❑ Uncertain diagnosis following non-invasive test and need to confirm diagnosis, OR ❑ Systolic dysfunction with unexplained cause, OR ❑ Survivor of sudden cardiac death, polymorphic VT, or sustained monomorphic VT, OR ❑ Suspected spas m or non-atherosclerotic cause of ischemia

Obtain a detailed history History of present illness ❑ Age ❑ Chest pain or chest discomfort ❑ Onset of symptoms ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration of each episode ❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium ❑ Timing of symptoms (morning vs. evening vs. wake patient at night) ❑ Alleviating factors (e.g. medications or rest) ❑ Exacerbating factors ❑ Association of symptoms to food intake ❑ Palpitations ❑ Nausea or vomiting ❑ Sweating ❑ Dyspnea ❑ Orthopnea ❑ Dizziness ❑ Weakness of extremities ❑ Numbness of tingling of extremities ❑ Lightheadedness ❑ Syncope or presyncope ❑ Increased frequency of symptoms ❑ Worsening of symptom severity ❑ Previous episodes ❑ Recent infections ❑ Fever ❑ Weight or appetite changes ❑ Stress ❑ Fatigue Possible triggers of symptoms ❑ Physical exertion ❑ Air pollution or fine particulate matter ❑ Recent infection ❑ Heavy meal intake ❑ Cocaine ❑ Marijuana Cardiovascular Risk Factors ❑ Known CAD (review available catheterizations or CABG reports) ❑ Smoking history ❑ Baseline blood pressure (Duration, antihypertensive therapy, compliance with medications) ❑ History of diabetes mellitus (Duration, DM control, compliance, antidiabetic medications, recent HbA1c, screening for micro- and macrovascular DM complications) ❑ Dyslipidemia ❑ Obesity (BMI > 30 kg/m2) Past Medical History ❑ Congenital heart disease ❑ Left to right shunts ❑ Dextrocardia ❑ Situs inversus ❑ History of renal disease (CrCl < 60 mL/min) ❑ History of bleeding tendency ❑ Known significant anemia (Hct < 30%) ❑ History of heparin-induced thrombocytopenia (HIT) ❑ History of pulmonary disease ❑ History of major surgery in the past month ❑ Anticipated major surgery in the next year Medications ❑ Prescribed drugs ❑ Home oxygen therapy ❑ Over-the-counter drugs ❑ Herbs and supplements ❑ Administration of ANY of the following medications within the last 48 hours prior to catheterization? ❑ Aspirin ❑ Clopidogrel ❑ Metformin ❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs) ❑ Warfarin. If yes, what is most recent INR? ❑ Low molecular weight heparin (LMWH). If yes, when was last dose? ❑ Other chronic anticoagualants (e.g. dabigatran, NOACs, fondaparinux) Allergies ❑ List of allergies, including severity and manifestations (pruritus, rash, hives, stridor, or anaphylactic shock) ❑ Known drug allergies ❑ Allergy to aspirin or history of nasal polyps or aspirin desensitization ❑ Allergy to heparin ❑ Other drug allergies ❑ Contrast allergy ❑ Latex allergy ❑ Allergy to Shellfish (controversial association between shellfish allergy and contrast allergy) ❑ Other known environmental and food allergies Family history ❑ Family history of premature cardiovascular diseases Social and Sexual History ❑ Healthcare proxy and available family members for patient care ❑ Barrier to tolerate or adhere to dual antiplatelet therapy (DAPT) or follow-up visits ❑ Pregnancy or possible pregnancy Advanced Directives ❑ DNR status ❑ DNI status

Examine the patient: ❑ Vital signs, including BP, HR, RR, T, room air SpO2 ❑ Height, weight, and body mass index (BMI) ❑ Level of consciousness, orientation, and ability to cooperate and communicate Skin ❑ Xanthelesma or xanthoma (suggestive of dyslipidemia) ❑ Edema (suggestive of congestive heart failure) ❑ Acral and/or central cyanosis HEENT ❑ Head and neck range of motion ❑ Modified Mallampati score ❑ Class I: Soft palate, uvula, fauces, pillars visible ❑ Class II: Soft palate, uvula, fauces visible ❑ Class III: Soft palate, base of uvula present ❑ Class IV: Only hard palate visible Cardiothoracic ❑ Auscultation of heart sounds (including number of sounds, pitch, interval, murmurs, gallops, or rubs) over 4 precordial regions in sitting position (stethoscope diaphragm) and auscultation of mitral area while in left lateral decubitus position (stethoscope bell) ❑ Normal S1 and S2 ❑ S3 may be pathologic or may be a normal finding in young or pregnant ❑ S4 may be pathologic or may be a normal finding in elderly ❑ Murmur may be physiologic or may suggest valvulopathy or hemodynamic derangement (e.g. anemia) ❑ Pericardial friction rub may suggest pericarditis ❑ Point of maximal impulse (PMI) (normally one, non-sustained, tapping impulse per cardiac cycle located less than 2-3 cm from midclavicular line at 5th intercostal space) ❑ Auscultation of anterior and posterior pulmonary regions bilaterally ❑ Crackles suggest pulmonary edema, which might be attributed to congestive heart failure ❑ If pulmonary auscultation abnormal, egophony, tactile fremitus, and thoracic percussion may be needed Vascular ❑ Pulses of both upper extremities (radial, ulnar, brachial) and lower extremities (dorsalis pedis, posterior tibial, popliteal) ❑ Femoral pulses bilaterally ❑ Femoral auscultation bilaterally for bruits ❑ Modified Allen test bilaterally to evaluate adequacy of radial access ❑ Carotid auscultation bilaterally ❑ Jugular venous pressure Neurological ❑ Upper/lower extremity motor strength ❑ Upper/lower extremity sensory exam ❑ Spasticity or rigidity ❑ Deep tendon reflexes ❑ Bilateral Babinski ❑ CN assessment ❑ Coordination and cerebellar exams (Finger to nose, Romberg, Heel to shin, alternating movement) ❑ Gait

Provide patient appropriate counseling before catheterization ❑ Address individual concerns and questions Hold Food Intake Before Procedure ❑ Keep patient NPO at least 6 hours before elective coronary angiography Hold Certain Medications Before Procedure Warfarin ❑ Hold warfarin for at least 2 to 6 days before elective coronary angiography (to prevent bleeding). ❑ Confirm INR < 1.8 (preferable INR < 1.4) within 24 hours before arterial puncture ❑ Restart warfarin 12 to 24 hours following catheterization (warfarin requires 2 to 3 days for INR to become therapeutic range) ❑ Consider heparin bridging 3 days before planned catheterization for high risk patients to prevent prolonged subtherapeutic INR ❑ Therapeutic dose LMWH 1 mg/kg subcutaneously twice daily for high-risk patients who are not at high risk of bleeding ❑ Intermediate dose LMWH 40 mg subcutaneously twice daily for high-risk patients at high risk of bleeding Novel Oral Anticoagulants ❑ Hold NOAC before catheterization as follow ❑ Rivaroxaban: Hold rivaroxaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ Apixaban: Hold apixaban for 2 days in patients with low bleeding risk OR for 3 days in patients with high bleeding risk ❑ If patient does not develop any hematoma, restart NOAC 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk. Dabigatran ❑ Hold dabigatran based on renal function as shown below. ❑ CrCl > 50 ml/min: Hold dabigatran for 1 day if low/intermediate bleeding risk or 3 days if high bleeding risk (e.g. major surgery) ❑ CrCl between 30 and 50 ml/min: Hold dabigatran for 3 days if low/intermediate bleeding risk or 5 days if high bleeding risk (e.g. major surgery) ❑ CrCl < 30 ml/min: Hold dabigatran for 2 to 5 days if low/intermediate bleeding risk or > 5 days if high bleeding risk (e.g. major surgery) ❑ If patient does not develop any hematoma, restart dabigatran 1 day after the catheterization for patients with low bleeding risk OR 2-3 days after the catheterization for patients with high bleeding risk. LMWH ❑ Hold LMWH for 12 hours before cardiac catheterization ❑ Resume LMWH 12-24 hours following cardiac catheterization Metformin ❑ Hold metformin 2 days before elective coronary angiography. ❑ Restart metformin 2 days post-procedure OR until creatinine is stable (to prevent lactic acidosis and contrast-induced renal failure) Phosphodiesterase inhibitors ❑ Hold sildenafil/tadalafil/vardenafil for at least 2 days before elective coronary angiography

Identify ASA physical status ❑ 1. Healthy individual with no systemic diseases ❑ 2. Mild systemic disease ❑ 3. Severe systemic disease ❑ 4. Severe systemic disease that poses a constant threat to the patient’s life ❑ 5. Moribund patient not expected to survive without the operation/procedure ❑ 6. Patient declared brain-dead or whose organs are being removed for donation

ASA physical status ≥ 4

ASA physical status < 4

Consult anesthesia

Perform pre-procedure routine work-up ❑ Complete blood count (CBC) ❑ Platelet count (Administration of unfractionated heparin, low molecular weight heparinoids, and parenteral glycoprotein 2b3a inhibitors are associated with thrombocytopenia. Thrombocytopenia is a contraindication to the administration of parenteral glycoprotein 2b3a inhibitors) ❑ Electrolytes panel ❑ Baseline serum creatinine and BUN ❑ Glycemia ❑ Beta-HCG within 2 weeks of procedure for women of child-bearing age ❑ Baseline ECG within 24 hours of procedure ❑ Assess baseline ischemic changes ❑ Presence of baseline bundle branch block (BBB) (Cardiac catheterization may damage HIS system and induce BBB) ❑ PT/INR within 24 hours, especially if patient receiving warfarin (INR > 1.8 is a relative contraindication of cardiac catheterization) ❑ CXR if patient suspected to have pulmonary edema or other diseases

Address specific significant comorbidities ❑ Prolonged INR (>1.8) 24 hours prior to procedure ❑ Administer low-dose vitamin K 1-2 mg PO ❑ Repeat INR and confirm new INR < 1.8 (preferable INR ≤ 1.4). If INR still > 1.8: ❑ Administer additional vitamin K 2-4 mg PO if anticipated procedure is > 24 hours later. Administer more doses of low-dose vitamin K (1-2 mg PO) if INR still high ❑ Cancel transfemoral approach (except if emergency) if INR does not normalize in time of procedure ❑ Consider transradial approach if radial artery accessible to reduce risk of bleeding ❑ Consider transfusion of fresh frozen plasma (FFP) ❑ Renal insufficiency (CrCl < 60 ml/min) ❑ Saline administration ❑ In patients with no CHF, administer 0.9% or 0.45% normal saline: 1 mL/ kg/ hour (MAX 100 ml/hour) for 12 hours before contrast AND 12 hours after contrast ) in patients with no CHF ❑ In patients with CHF, administer 0.45% normal saline: 0.5 ml/kg/hr (MAX 50 ml/hr) 12 hrs before contrast AND 12 hours after contrast ❑ Consider administration of NaHCO3 ❑ Mix 150 mEq of NaHCO3 in 1 liter of D5W in non-diabetic patients OR mix 150 mEq of NaHCO3 in 1 liter of sterile water in diabetic patients. ❑ Administer 3 ml/kg bolus (MAX 300 ml) for 1 hour prior to procedure AND 1 mL/kg/hour (MAX 100 ml/hr) during the procedure AND 1 mg/kg/hour for 6 hours post-procedure ❑ Follow-up serum creatinine 3 to 5 days following catheterization ❑ Contrast allergy ❑ Administer the following regimen before the procedure (controversial timing) ❑ Regimen 1 ❑ Methylprednisolone 60 mg IV once, AND ❑ Diphenhydramine 50 mg IV once, AND ❑ Cimetidine 300 mg (or alternative H2 blocker) IV once ❑ Regimen 2 ❑ Prednisolone 50 mg PO at 13 hours, 7 hours, and 1 hour (total of 3 doses) before procedure

Confirm pre-procedure checklist ❑ Identified indication for procedure ❑ Planned procedure ❑ Diagnostic cardiac catheterization ❑ Diagnostic cardiac catheterization with possible PCI ❑ PCI ❑ Appropriate history and physical examination documented in patient record ❑ Informed consent is filled within 30 days, complete, signed, and available in patient record Candidacy for DES: ❑ Does the patient have significant anemia (Hct < 30%) ❑ Has the patient had any major surgery in the past month or is anticipating any major surgery in the next year? ❑ Does the patient have clinically overt bleeding? ❑ Is the patient receiving chronic anticoagulation (e.g. warfarin or dabigatran) ❑ Does the patient have a history of medications non-adherence? ❑ Does the patient have someone available to transport to and from the hospital? Allergies and adverse drug reactions: ❑ Contrast allergy. If yes, was the patient pre-treated? ❑ Aspirin allergy. If yes, does the patient need desensitization? ❑ Latex allergy: If yes, remove all latex products from procedural use ❑ Heparin induced thrombocytopenia (HIT): If yes, consider alterative antithrombotic agent ❑ Patient known to have multiple allergies? If yes, did you consider pretreatment? Medications ❑ Was the patient administered ANY of the following medications within the last 48 hours prior to catheterization? ❑ Aspirin ❑ Clopidogrel ❑ Metformin ❑ Phosphodiesterase inhibitors (e.g. Tadalafil, sildenafil, or similar drugs) ❑ Warfarin. If yes, what the patient’s pre-op (within 48 hours) INR? ❑ Low molecular weight heparin (LMWH). If yes, when was last dose? ❑ Other chronic anticoagualants (e.g. dabigatran, NOACs) ❑ ASA physical status available ❑ Modified mallampati score available ❑ Does patient have any contraindication to sedation? ❑ Pre-procedural work-up available AND reviewed (CBC, electrolytes, glycemia, PT/INR, creatinine, BUN, PT/INR within 24 hours if receiving warfarin, ECG within 24 hours, CXR if applicable) ❑ Renal function (serum creatinine) ❑ Bleeding risk (anemia, thrombocytopenia, prolonged INR/PT) ❑ Cardiac assessment (ECG)

Administer Preprocedural Drugs Dual antiplatelet therapy ❑ Administer aspirin 325 mg PO once at least 2 hours before the procedure, AND ❑ Administer clopidogrel 600 mg PO once at least 2 to 6 hours before the procedure Conscious Sedation ❑ Administer diazepam 5-10 mg PO once (additional drugs, such as fentanyl 25 to 50 microgram IV AND midazolam 1 to 2 mg IV, may be administered pre-procedure, but are usually administered once patient is inside the cath lab) Consider antihistamine ❑ Consider administration of diphenhydramine (Bendaryl) 25 mg PO once Consider anti-nausea agents ❑ Consider administration of ondansetron (Zofran) 4 mg IV once

❑ Transfer patient to cath lab